A Therapy Fell Out of Favor, But Didn't Stop Saving Lives

By DENISE GRADY

Published: January 17, 2006

Two months ago, when her surgeon recommended a series of treatments that would pump drugs directly into her abdominal cavity to fight advanced ovarian cancer, Gail Hilvers called her chemotherapy doctor to request it. He flatly refused.

''He said no research showed it was effective,'' said Ms. Hilvers, who is 51.

But she trusted her surgeon, so she decided to have the abdominal treatments, even though it would mean repeated 92-mile trips from her home in Ripon, Calif., to Stanford University Hospital.

Now, she is feeling especially lucky that she took the surgeon's advice. On Jan. 5, a large study was published showing that abdominal treatment, combined with the usual intravenous chemotherapy, could add 16 months or more to the lives of many women with advanced ovarian cancer -- a survival increase so large that it would be considered a major advance in any type of cancer.

The study, in The New England Journal of Medicine, was actually the third in a decade to show that abdominal chemotherapy could help patients. It employed two widely used generic drugs, cisplatin and paclitaxel.

Experts said medical practice should change immediately, and the National Cancer Institute took the rare step of issuing a formal announcement to encourage doctors to offer the treatment to all women who met the medical criteria for it.

At major cancer centers and some other hospitals, the abdominal treatment was already in use, often as part of research, sometimes outside of studies. And although the latest findings were in women with newly diagnosed ovarian cancer, some doctors also use abdominal chemotherapy to treat recurrences of the disease.

As Ms. Hilvers quickly learned, the treatment a woman gets can depend heavily on who her doctor is and whether she can travel to a distant clinic.

Many cancer specialists, like the doctor who refused to treat Ms. Hilvers, have been skeptical about the abdominal technique, also known as intraperitoneal therapy, or IP. There are numerous reasons. The procedure is more difficult and time-consuming than dripping chemotherapy into a vein, and doctors and nurses need special training to administer it.

IP uses higher drug doses that can have severe side effects, including permanent nerve damage. Surgeons have to learn how to implant a special device called a port and a catheter in the abdomen to deliver the chemotherapy. Not every woman can have the implants; some have too much scar tissue.

Another strike against IP in some doctors' minds may be that it is not new. Many doctors lost interest in it years ago because different formulations were tried for ovarian cancer in the 1980's and 90's, but none proved better than traditional treatments. And drug companies, a source of information for many doctors, have not been promoting IP: there is relatively little profit in it for them, since the most effective formula for ovarian cancer uses generic drugs.

Ms. Hilvers's surgeon, Dr. Nelson Teng, director of gynecologic oncology at Stanford University Hospital, said that in the past some doctors gave up on the treatment because the implanted catheters tended to become clogged by scar tissue or caused infections.

''There are many little tricks,'' Dr. Teng said, adding that he had been implanting the ports and catheters for about 20 years. ''It's almost like an art, how to place this catheter correctly. That's another reason why it's not widely used.''

The need to overcome doctors' reluctance is part of what drove the cancer institute to campaign for the treatment, said Dr. Edward Trimble of the division of cancer treatment and diagnosis. Details about the treatment, including a list of hospitals around the country that can provide it, are posted at ctep.cancer.gov/highlights/ovarian.html. Information is also available by telephone from the institute's Cancer Information Service: (800) 4-CANCER.

''Since there has been a prejudice against this, it's important for women and their families to ask about it,'' Dr. Trimble said. ''If patients ask, the doctor is more likely to raise the issue and say, 'I need to learn how to do this.' Advocacy groups have to get the word out to patients.''

Dr. Joan L. Walker, a gynecologic oncologist at the University of Oklahoma and an author of the latest study, said: ''The two previous studies had flaws that gave people excuses for why they didn't use it. Now we have three papers that all say same thing. One study can be a fluke, a statistical anomaly. Three probably isn't.''

The latest study included 415 patients with advanced ovarian cancer, most ages 41 to 70, at 40 hospitals around the United States. All had surgery, and then were picked at random to get either intravenous chemotherapy alone, or both intravenous and IP therapy.

The median survival in the intravenous group was 49.7 months, but in those who got IP therapy it was 65.6 months -- a difference of 15.9 months. This was the largest survival increase ever seen in any gynecologic cancer.

In response to a news article about the study, several patients contacted The New York Times to say they had IP therapy for ovarian cancer long ago and may owe their lives to it. One, Helen Palmquist, of Lincolnshire, Ill., had high doses of IP cisplatin 18 years ago at Northwestern University when she was 42.